- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,623.41 / $14,125.38
| Facility | | $1,202.26 | $5,623.41 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $436.52 / $1,174.90
| Professional | | $257.04 | $436.52 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,000.00 / $1,819.70
| Professional | | $660.69 | $1,000.00 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $630.96 / $2,818.38
| Facility | | $309.03 | $630.96 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,071.52 / $1,995.26
| Professional | | $645.65 | $1,071.52 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,548.82 / $2,344.23
| Professional | | $977.24 | $1,548.82 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $562.34 / $1,905.46
| Facility | | $309.03 | $562.34 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $562.34 / $1,000.00
| Professional | | $60.26 | $562.34 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $1,258.93 / $2,187.76
| Professional | | $407.38 | $1,258.93 | $2,187.76 |